Since january 1st of this year, people over 65 years old had a fall in Europe, sometimes with serious consequences.
Since january 1st of this year, people over 65 years old had a fall in Europe, sometimes with serious consequences.
It should include a detailed inquiry concerning your medical history, lifestyle and the layout of your home as well as a review of your various treatments. It should also comprise a thorough and detailed physical examination, notably taking into account neurological, locomotor and cardiovascular examinations, the taking of arterial tension in the sitting (or supine) and standing position, the evaluation of visual and hearing capacities and an examination of your feet.
Such a comprehensive evaluation of an elderly individual should also explore cognitive functions, autonomy, their nutritional state and the various illnesses which, when combined, make it possible to have a precise idea of the fall risk.
Falls among the elderly are most often the result of a multifactorial process but gait and balance impairments have a great impact on fall risks. These impairments are among the functional deficiencies most frequently observed in very old and fragile individuals. Such an approach towards balance and gait capabilities therefore provides much information and enables a quick screening.
The main tests are as follows:
2.1 The Tinetti test
or POMA (Performance-Oriented Mobility Assessment).
The Tinetti assessment makes it possible to estimate and validate the fall risk. This tool enables a precise evaluation of balance and gait defects in seniors over various daily life situations. The examiner is not required to have any specific experience.
It is divided in two parts: the first stage studies balance defects based on 9 postural situations and the second one studies gait.
Part 1 - Balance: the patient is sitting in a chair with no armrests:
1- Balance when sitting on the chair
0- leans over to the side, slides from the chair / 1- steady, stable
2- If possible, stand up without supporting yourself on the armrests
0- impossible without assistance
1- possible but requires help from the arms
2- possible without needing the arms
3- Attempt to stand up
0- impossible without assistance
1- possible, but after many attempts
2- possible at the first attempt
4- Balance immediately after standing up (first 5 seconds)
0- unsteady (staggering, teetering)
1- steady, but requires a technical aid when standing
2- steady with no technical aid
5- Test to see whether balance is upset when attempting to stand up with your feet joined
0- unsteady
1- steady, but with feet widely apart or with a technical aid
2- steady, feet joined
6- Test to see whether balance is upset when nudged (the patient is standing with his feet joined, the examiner gives him 3 gentle nudges on the sternum)
0- begins to fall
1- staggers, holds onto something, regains his stability
2- steady
7- Eyes closed
0- unsteady / 1- steady
8- 360° rotation
0- discontinuous steps/ 1- continuous steps
0- unsteady (staggers, holds onto something) / 1- steady
9- Sitting down
0- unsafe, unable to assess distances correctly, let himself fall down onto the chair 1- use the arms or not a smooth motion
2- safe, smooth motion
Part 2 - Gait: the patient must walk at least 3 metres forward, do a half turn and come back to the chair with quick steps. He must use his usual technical aid (cane or walker)
10- Initiation of gait (right after the start signal)
0- hesitation or many attempts to start / 1- no hesitation
11- The right foot:
0- does not go past the left foot / 1- goes past the left foot to rest
0- does not leave the floor completely / 1- gets completely off the floor
12- The left foot:
0- does not go past the right foot / 1- goes past the right foot to rest
0- does not leave the floor completely / 1- gets completely off the floor
13- Gait symmetry
0- the length of right and left steps appears to be unequal
1- the length of right and left steps appears to be equal
14- Step continuity
0- stops or discontinuity between steps
1- steps appear to be continuous
15- Deviations from the trajectory (observed over a distance of 3m)
0- marked deviation along an imaginary line
1- slight deviation, or use of a technical aid
2- no deviation and no use of a technical aid
16- Trunk stability
0- marked swaying or use of a technical aid
1- no swaying, but leaning or swaying of the arms
2- no swaying, no need to support himself on an object
17- Walking stance
0- heels apart
1- heels almost touching while walking
The final score normally obtained is 28.
Interpretation of the final score
28 = normal
24-27 low risk
20-23 high risk
<20 very high fall risk, correlated with a fall risk multiplied by 5.
Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986; 34:119-26
In a more recent study, Tinetti presented a scale reduced to 7 items rated according to 2 levels (normal, abnormal) which seems to be a good reflection of the fall risk. The part concerning balance defects of the unabridged test is based on 13 items rated according to 3 levels and its study of gait is based on 9 additional items rated according to 4 levels.
In conclusion, this tool makes it possible to precisely assess balance and gait defects among seniors over several daily life situations. It is however somewhat long to carry out and requires active participation from the subject.
2.2 The 'Get Up and Go' test:
The 'Get Up and Go' test, which was also approved for senior patients, is quicker and simpler to carry out.
It is performed as follows: the patient must stand up from a seat with armrests, walk over a distance of 3 metres, do a half turn, come back towards the seat, walk around it and sit down. Results are expressed according to a relatively vague scale rated from 1 to 5.
Rating:
1- no unsteadiness
2- slightly abnormal; slow to carry out the instructions
3 fairly abnormal: hesitation, compensating movements of the upper limbs and trunk
4 abnormal: the patient stumbles
5 highly abnormal: constant fall risk.
For each question, a score of 3 or higher is a reflection of an important fall risk and should serve as a warning signal.
A timed version of this test is also possible: if it takes less than 20 seconds to carry it out, results are considered to be normal, i.e. showing good motor autonomy. On the contrary, if more than 30 seconds are required, it indicates a certain motor dependency and that the person might need special care. Lastly, the motor skills of patients who take between 20 and 30 seconds to carry out the test cannot be assessed for certain.
All in all, while this test makes it possible to quickly assess movement capabilities, its value as a tool to predict fall risks has not been established: the correlation between the 'Get Up and Go Test' and fall risks was never scientifically proven.
2.3 The Berg Balance Scale
This test assesses balance based on the observations made while the patient performs 14 usual daily life movements.
1. - Remaining seated on a chair with no back or armrests,
2. - Standing up,
3. - Sitting down again,
4. - Going from one chair to another,
5. - Standing without the support of any object,
6. - Remaining standing, eyes closed,
7. - Remaining standing, feet touching each other,
8. - Remaining standing, one foot in front of the other,
9. - Remaining standing on one foot,
10. - Rotating the trunk,
11. - Picking up an object from the floor,
12. - Doing a 360° rotation,
13. - Standing on a footstool,
14. - Leaning forwards.
The rating system is a 5-level scale: each item is graded from 0 (bad) to 4 (good). Here again, the scale is relatively vague, which makes it difficult to use as a reference test for scientific studies.
However, it was validated and is therefore used in rehabilitation centres, in the monitoring of patients following a cerebrovascular accident, for instance.
The maximum overall score is 56. Patients with a score over 45 are considered to have a good motor autonomy.
2.4 Unipodal support
This test was proposed by Prof Vellas's team: the ability to remain standing on one foot, the leg used for support in an extended position, the other slightly bended at the knee, with relaxed muscles, during 5 seconds appears to be a reliable test to predict the risk of injurious falls. Unfortunately, however, this test is unable to predict the general fall risk. Nevertheless, it is a quick and easy test which proves very useful in the systematic screening of fall risks among the elderly.
Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ - One-leg balance is an important predictor of injurious falls in older persons J Am Geriatr Soc 1997; 45 : 735-738.)
2.5 The 'Stops walking when talking' test
This interesting test was proposed by the team from Ste-P�rine hospital in Paris. It is based on the principle that individuals who present a higher fall risk find it difficult to make conversation as they walk. The attention required to carry on the conversation forces them to stop walking.
Verlhac B, Dieudonn� B, Vitale G, Forette B. �tude de la faisabilit� d'un nouveau test pr�dictif du risque de chute du sujet tr�s �g� pr�sentant des troubles cognitifs : Le 'stops walking when talking' [Feasibility study of a new test to predict fall risks among very old persons with cognitive impairments: the 'Stops walking when talking' test], L' Ann�e g�rontologique 2000 [The year 2000 in gerontology], vol. 14, pp. 361-38.
2.6 Minimum motor test
Decubitus
- Able to roll over and lie on their side: no = 0 / yes = 1
- Able to sit up on the edge of the examination table: no = 0 / yes = 1
Sitting position
- Normal sitting balance (no retropulsion): no = 0 / yes = 1
- Able to bend their trunk forwards: no = 0 / yes = 1
- Able to stand up from a seat: no = 0 / yes = 1
Standing position
- Possible: no = 0 / yes = 1
- Without the help of a person or object: no = 0 / yes = 1
- Bipodal position, eyes closed: no = 0 / yes = 1
- Unipodal position with support: no = 0 / yes = 1
- Normal standing balance (no retropulsion): no = 0 / yes = 1
- Postural adaptation reactions: no = 0 / yes = 1
- Parachute reactions:
* upper limbs (forward movements): no = 0 / yes = 1
* lower limbs (forward movements): no = 0 / yes = 1
* lower limbs (backward movements): no = 0 / yes = 1
Walking
- Possible: no = 0 / yes = 1
- Without the help of a person or object: non = 0 / oui = 1
- Unwinding of the foot as it lands on the ground: no = 0 / yes = 1
- No knee flexum: no = 0 / yes = 1
- Normal dynamic balance (no retropulsion): no = 0 / yes = 1
- Able to do a smooth half turn: no = 0 / yes = 1
TOTAL = /20
Camus A, Mourey F, D'Athis P, Blanchon MA, Martin-Hunyadi C, De Rekeneire N et al. Test moteur minimum. [Minimum motor test] Rev G�riatr 2002;27(8):645-58.(45)
For more information:
A great number of tests have been proposed by various teams, but all have not been validated for elderly patients. Moreover, not all of them can be used by physicians in their daily practice.
- Postural Stress Test (PST):
it evaluates the subject's postural reactions when suddenly thrown off balance backwards. The test's value as a predictive tool has not been established.- Functional Reach Test:
The patient is in a standing position, barefoot, with one arm stretched out in front of them and must lean forward as much as they can without losing their balance. The maximum distance they can reach is then measured with a ruler fastened to the wall (by subtracting the value of the arm length).
- Clinical Test of Sensory Interaction and Balance (CTSIB):
- Fast Evaluation of Mobility, Balance and Fear (FEMBAF):
It assesses the presence of fall risk factors, and the subject's functional capacities and physiopathological limitations. Its practical value has yet to be established.
- Extra-Laboratory Gait Assessment Method (ELGAM):
It assesses balance and various gait parameters. Its predictive value has not been established.
- Gait Abnormality Rating Scale (GARS):
It assesses gait impairments. The predictive value of this test has not been studied.
- Health professionals also have many tools available to assess the fear of falling among seniors. The following examples can be mentioned:
The SAFFE - Survey of Activities and Fear of Falling in the Elderly (Lachman et coll.);
The ABC - Activities-specific Balance Confidence Scale (Powell et Myers);
The FES - Falls Efficacy Scale, which assesses the fear of falling during various daily life
activities (Tinetti et coll.).
